Many medical decisions require shared decision making

Many medical decisions require shared decision makingThe following column was published on April 1, 2012 in USA Today.

I recently saw a middle-age man in my primary care clinic who asked whether he should continue his cholesterol medication. He was reacting to new Food and Drug Administration warnings on statins, a class of drugs taken by more than 20 million Americans to lower their cholesterol. Though generally safe, statins can slightly increase the risk of diabetes, as well as mild, reversible memory loss, according to the new warnings.

My patient and I discussed several scenarios, trying to balance these risks against the drug’s benefit of preventing heart attacks. Should he discontinue his statin? Lower the dose? Or change to a less potent drug within the same class? With no obvious answer, I finally asked my patient, “What do you think?” It’s a question more doctors need to ask.

Involving patient input in medical decisions is a concept known as shared decision-making. According to the Institute of Medicine, it is a foundation of patient-centered care, where care is “responsive to individual patient preferences, needs and values.”

Options sometimes limited

Of course, some cases have only one acceptable option: vaccinating children, or surgery for an acute case of appendicitis, for instance. But in the majority of cases, the correct treatment is much less clear. Issues such as cancer screening, end-of-life decisions and whether to pursue elective surgery all have multiple feasible paths. That’s where shared medical decision-making plays a valuable role.

My patient, for instance, didn’t have a history of heart disease, which weakens the case for statin drugs. Cardiologist Eric Topol of the Scripps Clinic in San Diego says the reduction of heart attacks in patients like mine was 1 in 50, while 1 in 200 patients would get diabetes because of the drug.

So should a patient try to prevent heart attacks at all costs, and accept the drug’s side effects? Or is the risk of diabetes too great? The answer will vary, based on the preferences and values of individual patients.

Benefits are many

The benefits of engaging patients are significant. A 2011 Cochrane review, which analyzes the results of medical research, looked at 86 studies that examined patients who used decision aids — such as pamphlets, videos or Web-based tools — to help them make medical decisions. When these tools were used, patients reported an improved knowledge of their options, held more accurate expectations of harms and benefits, and reached choices consistent with their personal values.

But doctors often take a paternalistic approach to care, simply making the decision they think is best. Consider prostate cancer screening, where updated guidelines from the U.S. Preventive Services Task Force have made the decision of whether to pursue testing less certain. The estimated benefit of finding early prostate cancer has been reduced in recent studies, and further diluted by the harms that stem from prostate cancer treatment, which include impotence and urinary incontinence. Despite the complexity of that decision, a 2009 study in the Archives of Internal Medicine reported that barely half of patients recalled being asked for their screening preferences.

Back to my patient. After carefully considering his options, he decided to stop taking the statins. But had he decided otherwise, I would have respected his informed choice and continued the medication. The voice of patients needs to be considered for most medical decisions. That way, no matter what choice is made, it will always be the right one.

Many medical decisions require shared decision makingKevin Pho is co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • JPedersenB

    You are exceptionally open-minded for a physician!  For far too many people, their doctor will pooh pooh (or ridicule) their concerns and insist on the patient continuing on the drug because that is what the guidelines say.  If we are to even get on the road to real reform in the medical industry, doctors must stop giving “orders” that must be obeyed, or else!  I find it shocking that so many doctors are seemingly unaware of drug side effects  and the costs of drugs/tests /procedures/ etc. that they are ordering.

    • southerndoc1

      Actually, we’re headed towards more pay-for-performance programs, where the doc will be financially punished for every patient who chooses not to take a statin. Look forward to lots of one-size-fits-all medicine.

      • Dorothygreen

        Tell me please how this will work .  I cannot understand that with all that is being done now to pull patients into the decision making process, make EVERYONE more responsible, voluntary efforts from physicians like the “Choose wisely” program, as well as the pay for performance, electronic medical records, that there is no way to avoid the one-size-fits all and how docs will be financially punished..

        It is here that the US has a golden opportunity to put measures in place that other countries have not done so well – even Switzerland, who has developed a pretty good health care system, remaining private, and keeping costs under control  – has such issues as you describe.  

        Why would it be so difficult to develop a computer check list for such issues, even print it out and have the patient sign it.  The decision not to take a statin is that of the patient’s.  If the doc has done everything he or she can do according to guidelines, and counseled the patient on diet and exercise, then how could it be so easy for “financial punishment”?  There are plenty of patients already who are non-compliant regardless of what the doc says, even with health insurance, and will not change - those addicted to sugar, fat, sodium, alcohol, tobacco.  How did we manage to deal with a 65% of the population who were cigarette smokers (now 20%). It cannot be a solo physician’s responsibility to “make” a patient stop addictive behavior”.   

        The only way to address this is to get revenue from the products that are addictive (as well as decreasing their production) and puttting a message of risk on the products that are unhealthy (the tobacco model).  Provide funding to ACOs for monitored exercise program, nutritional assistance – education, education and counseling for social factors involved with overeating.  It is really a public health issue – more money here less needed for specialists in cardiac and diabetic care or billing or even for health care insurance profits.   The burden of cost should be upfront like tobacco smoking and not on increased insuance premiums or income tax. 

        Other countries seeing this trend of sugar, fat and salt addiction are already instituting measures to capture revenue up front and send a strong message.  None of them come close to the overeating epidemic with its chronic PREVENTABLE conditions as in the US.

         

  • http://twitter.com/WindyCityMed Michael Mank

    Do you think improving patient satisfaction through shared decision making improve patient outcomes? Or at least patient-perceived outcomes?

  • missiedog1

    Education will assist the patient as he/she makes the right decision for self. 

  • mikeyGee123

    when elderly people go to specialists..shouldn’t the primary act like the qaurterback and get all the information..or should everyone treat the patient seperately if the patient is seeing 3 different specialists 

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